Professional Case Management最新文献

Purpose: Interprofessional teams are increasingly being recognized as a best practice for enhancing cooperation among multiple disciplines in delivering person-centered care and improving outcomes. Unlike previous models, such as the multidisciplinary team in which each profession or discipline remained largely siloed, with interprofessional teams collaboration occurs across disciplines. For case managers, the interprofessional team concept aligns with the collaborative, professionally diverse nature of the field of practice. As the Commission for Case Manager Certification (CCMC) states: "The practice of case management is professional and collaborative, occurring in a variety of settings where medical care, mental health care, and social supports are delivered. Services are facilitated by diverse disciplines in conjunction with the care recipient and their support system" (2024b, CCMC Definition and Philosophy, p.1). Although interprofessional teams may be more familiar in settings such as acute care, this dynamic can be found, formally and informally, across health and human services. Professional case managers who actively participate in interprofessional teams will likely find more opportunities to optimize collaboration and collective decision-making that bring out the best of every profession and discipline.

Primary practice settings: Interprofessional teams can be found in multiple care settings including acute care, subacute care, community-based care, palliative/end-of-life and other settings that benefit from a person-centered approach that supports successful transitions of care and improved outcomes.

Implications for case management practice: Professional case managers are valued members of interprofessional teams, in that they are typically collaborative, promote open communication, and encourage cooperation among various disciplines. Interprofessional teams, however, may require a shift in thinking away from the former multidisciplinary model, in which case managers often acted as the hub connecting the spokes of each discipline. Within interprofessional teams, the individual is at the center, and every discipline will share leadership based on the individual's needs or the treatment protocol or other intervention needed in the moment. In this way, interprofessional teams become a model for empowering and allowing each discipline to step up and address specific aspects of treatment or other interventions.

Purpose of initiative: After noting an elevated chronic obstructive pulmonary disease readmission rate for 2022, the inpatient Nurse Navigator at a rural nonprofit, 116-bed acute care facility in the State of Virginia met with interdisciplinary team (IDT) members to identify improvement efforts to decrease 30-day readmission rates.

Primary practice setting: A 116-bed health care facility in Southside Virginia.

Methodology and sample: Quality improvement initiative aimed to decrease 30-day penalty readmission rates using a collaborative IDT approach, focusing on patients 65 years or older who are discharged home or to an assisted living facility with a diagnosis of acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia.

Results: Compared to the readmission rates obtained in 2022, the 2023 readmission rates among the four diagnoses groups met or were under the disease-specific targets for 2023, supporting the efforts of the collaborative interdisciplinary approach to decrease 30-day readmission rates.

Implications for case management practice: Addressing community barriers and social determinants of health at the index admission. Collaborating with IDT members for a safe transition of care. Using the community paramedic program to provide additional resources to a rural community.